Faculty Bibliography

BACKGROUND:Uncorrected superior glenoid wear in patients managed with reverse total shoulder arthroplasty (rTSA) can result in increased complications, including baseplate failure. The present study quantifies the clinical and radiographic outcomes of patients with Favard type-E1, E2, and E3 glenoid deformity who were managed with rTSA with use of a superior or superior/posterior augmented glenoid baseplate. METHODS:We retrospectively reviewed the records for 68 patients with shoulder arthritis and Favard type-E1, E2, or E3 glenoid deformity who were managed with primary rTSA and a 10° superior augmented or 10° superior/8° posterior augmented baseplate. The mean duration of follow-up was 40 months (range, 24 to 85 months). Outcomes were assessed preoperatively and at the latest follow-up with shoulder range of motion and use of outcome scores including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and Shoulder Pain and Disability Index (SPADI) score. Radiographs were evaluated preoperatively and at the time of the latest follow-up. Differences in preoperative and postoperative range of motion and outcome metrics were assessed with use of a 2-tailed Student t test. RESULTS:The majority of patients experienced clinically meaningful improvements in terms of pain and function following rTSA with a superior or superior/posterior augment, with 94% of patients rating themselves as "much better" (73.5%) or "better" (20.5%) at the time of the latest follow-up. At least 88% of the patients exceeded the minimum clinically important difference (MCID) threshold, and 75% of patients exceeded the substantial clinical benefit (SCB) threshold, for each of the clinical outcome metrics and range of motion. Five complications were reported (prevalence, 7.4%), including acromial stress fracture (2 patients), posttraumatic scapular neck fracture (1 patient), chronic shoulder pain (1 patient), and aseptic glenoid loosening (1 patient). CONCLUSIONS:The present short-term clinical and radiographic study demonstrated that shoulder arthropathy with superior glenoid wear patterns (Favard types E1, E2, and E3) can be successfully treated with rTSA with a superior or superior/posterior augmented baseplate. Longer-term clinical and radiographic follow-up is necessary to confirm that these promising short-term results are durable. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Latarjet-Patte procedure has a long and storied history that predates shoulder arthroscopy, but its popularity has increased over the past two decades as a treatment for anterior glenohumeral instability with bone loss. Transfer of the coracoid process and conjoint tendon to the anteroinferior glenoid creates a triple-blocking effect that is both static and dynamic, lending it biomechanical superiority over alternative bone block techniques. Patients undergoing the Latarjet-Patte procedure have low rates of recurrent instability compared to arthroscopic soft-tissue stabilization procedures, particularly in the setting of glenoid- and humeral-sided bone loss. A number of technical innovations have been developed in recent years to improve the efficacy of this procedure and to reduce its potential complications, although their associated learning curves and potential for widespread adoption remain unclear. In this article, we review the history, indications, outcomes, and future of this surgical technique.

BACKGROUND:Prosthetic joint infection (PJI) after total shoulder arthroplasty (TSA) is a devastating complication. Cephalosporins are considered the standard of care for antibiotic prophylaxis during TSA procedures; however reported β-lactam allergies may result in the use of less effective alternatives which are associated with higher infection and complication rates. The aim of this study is to evaluate the relationship between reported β-lactam allergies, antibiotic choice, and revision rates in TSA. METHODS:A retrospective chart review was conducted on all TSA procedures performed at a single institution between January 2015 and January 2025. Information was collected regarding reported allergies to antibiotics including allergy severity and specific reactions. Additionally, all antibiotics administered during the procedures, intraoperative reactions to administered antibiotics, surgical complications, and subsequent revision procedures were collected. Revision procedures were categorized as septic or aseptic based on preoperative diagnosis. Perioperative antibiotics and patient allergies were categorized into penicillins, cephalosporins, clindamycin, vancomycin and other. RESULTS:Data from 4,232 TSAs were collected. 23% of patients had a reported antibiotic allergy and 15% had a β-lactam allergy. Cephalosporins were administered in 94% of all TSAs, but use declined with increasing β-lactam allergy severity, dropping from 90% in mild cases to 44% in severe cases, with corresponding increases in clindamycin and vancomycin use. Higher allergy severity was strongly associated with reduced cephalosporin use and increased alternative antibiotic use (OR = 0.40, p<.001). Notably, cephalosporins were given to patients labeled as having anaphylactic reactions to penicillins or cephalosporins with no adverse events reported. Overall, intraoperative cephalosporin prophylaxis was significantly associated with decreased all-cause revision odds (OR = 0.47, p<.001) and the presence of a β-lactam allergy was associated with increased likelihood requiring a revision procedure for a presumed septic etiology. CONCLUSIONS:The severity of reported β-lactam allergies strongly influences perioperative antibiotic selection despite evidence that most reported allergies are unreliable, unnecessarily increasing patient risk for PJI. Lack of cephalosporin prophylaxis was associated with increased revision rates, underscoring the clinical and economic value of appropriate antibiotic use. Given the high prevalence of mislabeled β-lactam allergies, established delabeling strategies using allergy testing or test-dosing in the operating room may offer a safe and effective means to increase first-line antibiotic use and improve stewardship. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective Cohort Comparison, Prognosis Study.

BACKGROUND/UNASSIGNED:Advantages of preoperative planning computed tomography (CT) scans for shoulder arthroplasty (SA) are known; however, risks of ionizing radiation exposure remain unknown. We retrospectively reviewed institutional trends in utilization and estimated radiation risk of preoperative planning CT scans obtained for SA. METHODS/UNASSIGNED:From 2016 to 2024, the annual percent incidence of SA patients that received a preoperative planning CT was determined. The National Academy of Sciences Biological Effects of Ionizing Radiation VII report on lifetime attributable risk (LAR) cancer incidences and received radiation dose were utilized to estimate patient-level LAR projections for 100 patients stratified by sex, age, and cancer type. RESULTS/UNASSIGNED: = 0.78) from 53% to 66% of all SA patients. For all solid cancers, LAR (per 100,000 people) decreased as patient age increased, ranging from 73.1 to 9.6 for females and 40.7 to 31.4 for males (from the 50-59-year-old group to the 80-89 group). In the 60-69-year-old and 70-79-year-old groups, estimated thyroid and lung LARs were significantly higher in women. DISCUSSION/UNASSIGNED:Utilization of preoperative shoulder CT scans is increasing. Preoperative shoulder CT may be associated with a small but quantifiable projected cancer risk most pronounced in younger women.

BACKGROUND/UNASSIGNED:This study evaluates outcomes following internal fixation of unstable distal clavicle fractures (DCFs) with or without coracoclavicular (CC) stabilization. METHODS/UNASSIGNED:A retrospective review was conducted for patients who underwent open repair of unstable DCFs at a single institution from 2017 to 2024. Fixation techniques included locking plate alone (P) or plate with CC stabilization [transcoracoid suture button (P + B), coracoid anchor (P + A)]. Collected variables included demographics, clinical details, patient-reported outcome measurement information system (PROMIS) scores, American Shoulder and Elbow Surgeons (ASES) scores, and Visual Analog Scale (VAS) Pain. RESULTS/UNASSIGNED:Seventeen patients with DCFs (17 shoulders;11 males, 6 females; mean age 45 [23-78] years) were followed for an average of 32.0 (3.4-69.3) months. Fixation groups included P (6), P + B (8), and P + A (3). Neer types included IIA (4), IIB (6), and V (7). Mean outcome scores were PROMIS upper extremity 49.2 ± 10.5, pain interference 47.0 ± 7.2, pain intensity 39.3 ± 7.0, ASES 89.3 ± 14.3, and VAS 1.5 ± 2.2. Three patients (18%) experienced postoperative issues: plate prominence (2) and shoulder stiffness (1); none required reoperation. DISCUSSION/UNASSIGNED:The addition of CC stabilization to locking plate fixation in high-risk unstable DCFs results in favorable outcomes and predictable healing rates. LEVEL OF EVIDENCE/UNASSIGNED:IV, case series.

BACKGROUND:The use of large language models (LLMs) is increasingly common. However, LLMs may exhibit sycophancy, echoing users' beliefs while avoiding contradiction. In the present study, we describe sycophancy in general-purpose LLMs when applied to orthopaedic contexts. METHODS:We investigated sycophancy in 2 general-purpose LLMs. We evaluated performance on 3 tasks: (1) accuracy on benchmark answering: LLMs were tested on validated benchmark orthopaedic questions, with correct and incorrect cues, and the change in accuracy and sycophancy error rate were determined; (2) user belief agreement: LLMs were provided with ambiguous statements and a user belief, and LLM agreement, contradiction, and uncertainty were described; and (3) false information detection: false information was placed within a task prompt to measure noncontradiction and propagation rates. RESULTS:Baseline factual accuracy on benchmark questioning was 78%, decreasing with correct hints (71%) (p = 0.49). With incorrect hints, LLM accuracy declined significantly (48%) (p < 0.001), with a sycophancy error rate of 52%. Presented with user beliefs about an indefinite, controversial statement, models echoed user beliefs in 56%, expressed uncertainty in 12%, and contradicted users in 32% of statements. In noncontradiction tasks, models perpetuated incorrect attributions 99% of the time yet reliably corrected statistical distortions 97% of the time. CONCLUSIONS:Although popular general-purpose LLMs have useful orthopaedic applications, they exhibit sycophancy, with a tendency toward agreement and without recognition of ambiguity. This is a key weakness to be addressed. Findings should be interpreted cautiously given the variability in model design, prompting, and models evaluated. CLINICAL RELEVANCE/CONCLUSIONS:The tendency of general-purpose LLMs to agree without recognizing clinical ambiguity may limit their reliability in orthopaedic applications.

BACKGROUND/UNASSIGNED:The primary aim of this study is to evaluate differences in inpatient charges between primary (pTEA) and revision (rTEA) total elbow arthroplasty among Medicare and Medicaid patients. Our secondary aim is to assess whether these charges vary across hospitals with differing total elbow arthroplasty (TEA) procedural volumes. We hypothesize that rTEA would be more expensive than pTEA and that charges would be higher for low-volume hospitals. METHODS/UNASSIGNED:The Statewide Planning and Research Cooperative System database was queried for all Medicare and Medicaid Services patients who underwent a pTEA or rTEA in New York State from 2010 to 2020. Hospitals were classified as high-volume (≥3 surgeries/year), medium-volume (between 2-3 surgeries/year), or low-volume (less than 2 surgeries/year). Facilities performing fewer than 1 surgery per year or with fewer than 4 years of TEA data were excluded. Total inpatient charges were collected and subsequently subdivided into ancillary and accommodation charges. Inpatient charges and readmission data were compared across the 2 procedures and volume groups. RESULTS/UNASSIGNED:> .05 for rTEA). CONCLUSION/UNASSIGNED:rTEA is associated with longer inpatient stay, higher inpatient charges, and greater readmission rates compared to pTEA. Primary TEA in low-volume hospitals is associated with higher total charges compared to medium and high-volume hospitals. These findings provide valuable insights for hospital administrators and public health officials aiming to create effective strategies to manage costs and combat the growing burden of healthcare expenses in the United States.

BACKGROUND/UNASSIGNED:Three-dimensional (3D) preoperative planning and intraoperative computer-assisted navigation (CAN) may influence baseplate augmentation and screw fixation in reverse total shoulder arthroplasty (RTSA). This study evaluated how these technologies affect augmented baseplate use and screw length. This is a Level IV retrospective study. METHODS/UNASSIGNED:Three hundred primary RTSAs for glenohumeral degenerative conditions (2014-2024) were reviewed. Patients were divided into three groups: (1) 2D-CT planning without CAN (2014-2017, n = 100), (2) early 3D-CT with CAN (2019-2022, n = 100), and (3) recent 3D-CT with CAN (2022-2024, n = 100). Demographics, glenoid morphology, baseplate type, and screw characteristics were compared. RESULTS/UNASSIGNED:Augmented baseplate use was higher in the 3D-CT groups versus 2D-CT (40% and 43% vs. 15%; P < .01) with no demographic or glenoid morphology differences (P > .05). CAN was associated with longer screws when four screws were used (24.6 mm and 25.3 mm vs. 20.8 mm; P < .001) and when comparing the two longest screws (28.5 mm and 27.3 mm vs. 22.9 mm; P < .01). Screw length did not differ between augmented and standard baseplates. DISCUSSION/UNASSIGNED:3D planning and CAN increased augmented baseplate use and screw length. Equivalent screw lengths between augmented and standard baseplates suggest that augmentation does not compromise fixation, supporting its safe use in appropriately selected patients.

» Distal clavicle fractures are less common, accounting for 10% to 30% of all clavicle fractures. » The presence of radiographic nonunion does not correlate with symptomatic nonunion, with a variable percentage of patients necessitating subsequent surgical intervention (20%). » Fracture displacement is associated with a higher risk of nonunion (31%-37%), particularly in Neer type II and V fracture patterns. » Nondisplaced distal clavicle fractures can be treated with nonoperative management (Neer types I, III, and IV). » Surgical treatment is indicated for displaced Neer type II and V fractures. Increased radiographic coracoclavicular (CC) distance in type II and V fractures is an indication for CC stabilization. However, there is no consensus on ideal fixation techniques for fracture fixation and CC stabilization. » Surgical treatment may require secondary implant removal, regardless of the fixation construct used (28%-55%) but especially common with hook plate fixation.

BACKGROUND:Total shoulder arthroplasty (TSA) utilization has increased rapidly following the adoption of the reverse TSA (rTSA). Contemporary forecasts of TSA incidence and prevalence are limited and outdated, particularly in comparison with total hip arthroplasty (THA) and total knee arthroplasty (TKA). We sought to update TSA projections in the United States through 2040 and compare them against THA and TKA. METHODS:We identified adults (≥18 years) who underwent primary TSA, THA, or TKA between 2015 and 2025 in the United States using a large database. Annual incidence (new procedures per 100,000 patients) and prevalence (patients with prior arthroplasty per 100,000) were calculated. For each arthroplasty, linear and Poisson regression models were used to project new cases through 2040, with 95% confidence intervals. COVID year exclusion analysis and segmented analyses were performed using pre and post-COVID years in both linear and Poisson regression models to assess the effect of accelerated post-pandemic rebound. RESULTS:From 2015-2025, we identified 83,203 new TSA, 267,683 new THA, and 354,044 new TKA cases. TSA incidence increased from 13.1 to 45.6 per 100,000 (248.1% change), and prevalence from 41.5 to 222.8 per 100,000 (436.9% change). Across both modeling approaches, new cases for all procedures increased significantly. In Poisson modeling, the greatest proportional annual growth was observed for TSA (12.4% per year), compared with TKA (9.1% per year) and THA (8.5% per year). With linear regression, incidence increased by 2.77 cases per 100,000 per year for TSA, 8.75 for TKA, and 6.26 for THA, with TKA showing the largest additive yearly increase. By 2040, the linear model predicts that shoulder arthroplasty volume will increase by 73.0% to 78.9 cases per 100,000, whereas the Poisson model predicts a 397.4% increase, to 226.8 cases per 100,000. Utilizing post-COVID years, the linear model predicts that TSA volume will increase by 212.9% to 142.7 cases per 100,000, whereas the Poisson model predicts a 2317.8% increase, to 1102.5 cases per 100,000. CONCLUSION/CONCLUSIONS:TSA utilization in the United States has increased significantly over the past decade and is projected to continue rising through 2040. Although TSA remains less common than THA or TKA, it demonstrated the greatest proportional annual growth by Poisson modeling from 2015 to 2025, with much of this acceleration concentrated in the post-COVID period. These updated projections provide essential data for clinicians, health-system leaders, and policymakers as they plan for the growing burden of shoulder arthroplasty.